/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/hem---myeloma/,

/clinical/cckm-tools/content/beacon-protocols/hem---myeloma/name-96910-en.cckm

201611320

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Hem - Myeloma

CSC HEM Bortezomib(28D:1,8,15,22) Cyclophosphamide(28D:1,8,15,22) Dexamethasone(28D:1-4,9-12,17-20) VER 10-3-16 (HL 4415)

CSC HEM Bortezomib(28D:1,8,15,22) Cyclophosphamide(28D:1,8,15,22) Dexamethasone(28D:1-4,9-12,17-20) VER 10-3-16 (HL 4415) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Hem - Myeloma


CSC HEM BORTEZOMIB(28D:1,8,15,22)/CYCLOPHOSPHAMIDE(28D:1,8,15,22)/DEXAMETHASONE(28D:1-4,9-12,17-20) VER:
10-6-16 – Properties
Pre-Cycle – 11/8/2016 through 11/14/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 11/8/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
ranitidine (ZANTAC) 150 MG tab
Take 1 tab by mouth 2 times daily., 150 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
acyclovir (ZOVIRAX) 400 MG tab
Take 1 tab by mouth 2 times daily., 400 mg, Disp-60 tab, R-5, 2 X DAILY starting S, Local Printer
Cycle 1 – 11/15/2016 through 12/12/2016 (28 days), Planned
Day 1, Cycle 1 – Planned for 11/15/2016
Treatment Plan Information
Reference Information (1)
MULTIPLE MYELOMA: Reeder CB, et al. Leukemia 2009;23:1337-41.
Reference Information (2)
MULTIPLE MYELOMA: Reeder CB, et al. Blood 2010;115:3416-7.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 1 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Reference Information (3)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 40mg (10 tablets) by mouth on Day 1 through 4 , Day 9 through 12 and Day 17 through 20., Disp-120 tab, R-0, starting S,
Local Printer
cyclophosphamide (CYTOXAN) 50 MG cap
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 2 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Take 10.5 caps by mouth once weekly. Take on Days 1, 8, 15, and 22., 525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, EVERY 7 DAYS starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
BUN, Creatinine, Total Bilirubin, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
Day 8, Cycle 1 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 1 – Planned for 11/29/2016
Treatment Plan Information
Treatment Plan Summary
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 3 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 1 – Planned for 12/6/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.69 mg
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 4 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 2 – 12/13/2016 through 1/9/2017 (28 days), Planned
Day 1, Cycle 2 – Planned for 12/13/2016
Treatment Plan Information
Reference Information (1)
MULTIPLE MYELOMA: Reeder CB, et al. Leukemia 2009;23:1337-41.
Reference Information (2)
MULTIPLE MYELOMA: Reeder CB, et al. Blood 2010;115:3416-7.
Reference Information (3)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 5 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 40mg (10 tablets) by mouth on Day 1 through 4 , Day 9 through 12 and Day 17 through 20., Disp-120 tab, R-0, starting S,
Local Printer
cyclophosphamide (CYTOXAN) 50 MG cap
Take 10.5 caps by mouth once weekly. Take on Days 1, 8, 15, and 22., 525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, EVERY 7 DAYS starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
BUN, Creatinine, Total Bilirubin, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 6 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 8, Cycle 2 – Planned for 12/20/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 2 – Planned for 12/27/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 7 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 2 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 3 – 1/10/2017 through 2/6/2017 (28 days), Planned
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 8 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Day 1, Cycle 3 – Planned for 1/10/2017
Treatment Plan Information
Reference Information (1)
MULTIPLE MYELOMA: Reeder CB, et al. Leukemia 2009;23:1337-41.
Reference Information (2)
MULTIPLE MYELOMA: Reeder CB, et al. Blood 2010;115:3416-7.
Reference Information (3)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 9 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 1, 8, 15 and 22, 40 mg, Disp-40 tab, R-0, 1 X DAILY starting S, Local Printer
cyclophosphamide (CYTOXAN) 50 MG cap
Take 10.5 caps by mouth once weekly. Take on Days 1, 8, 15, and 22., 525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, EVERY 7 DAYS starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
BUN, Creatinine, Total Bilirubin, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
Day 8, Cycle 3 – Planned for 1/17/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 10 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 3 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 11 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 3 – Planned for 1/31/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Cycle 4 – 2/7/2017 through 3/6/2017 (28 days), Planned
Day 1, Cycle 4 – Planned for 2/7/2017
Treatment Plan Information
Reference Information (1)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 12 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

MULTIPLE MYELOMA: Reeder CB, et al. Leukemia 2009;23:1337-41.
Reference Information (2)
MULTIPLE MYELOMA: Reeder CB, et al. Blood 2010;115:3416-7.
Reference Information (3)
MYELOMA: Moreau P, et al. Lancet Oncol 2011;12:431-40.
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+7 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+7 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+7 Approximate, Expires-S+365, Routine
BUN
Expected-S+7 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+7 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+7 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+7 Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S+7 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Electrolytes, BUN, Creatinine, Total Bilirubin, AST, ALT.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 13 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 10 tabs by mouth one time daily. Take on Day 1, 8, 15 and 22, 40 mg, Disp-40 tab, R-0, 1 X DAILY starting S, Local Printer
cyclophosphamide (CYTOXAN) 50 MG cap
Take 10.5 caps by mouth once weekly. Take on Days 1, 8, 15, and 22., 525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2
Treatment plan BSA from recorded weight), R-0, EVERY 7 DAYS starting S, Local Printer
Follow-Up
DAY 8 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 15 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 22 FOLLOW-UP
CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC, ANC (DIFF if done locally), Electrolytes,
BUN, Creatinine, Total Bilirubin, AST, ALT; CHEMOTHERAPY ROOM APPOINTMENT: bortezomib for 30 minutes.
Day 8, Cycle 4 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 14 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 15, Cycle 4 – Planned for 2/21/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 15 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
Day 22, Cycle 4 – Planned for 2/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Multiple Myeloma: THERAPY: Cycle 1 and 2: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide
300 mg/m2 by mouth Day 1, 8, 15, 22, and dexamethasone 40 mg by mouth Day 1 through 4, 9 through 12 and 17 through 20:
Cycle 3 and 4: bortezomib 1.5 mg/m2 subcutaneous Day 1, 8, 15, 22, cyclophosphamide 300 mg/m2 by mouth Day 1, 8, 15, 22, and
dexamethasone 40 mg by mouth Day 1, 8, 15, 22; CYCLE LENGTH: 28 days; COURSE: 4 cycles
Nursing Procedure, Assessment and Monitoring
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
dexamethasone (DECADRON) tab 40 mg
40 mg, Oral, ONCE, 1 dose Starting when released
Omit if taken at home.
bortezomib (VELCADE) subcutaneous injection 2.69 mg
2.69 mg (rounded from 2.685 mg = 1.5 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Subcutaneous, ONCE, 1 dose
Starting when released
cyclophosphamide (CYTOXAN) cap 525 mg
525 mg (rounded from 537 mg = 300 mg/m2 × 1.79 m2 Treatment plan BSA from recorded weight), Oral, ONCE, 1 dose Starting
when released
Omit if taken at home.
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): cyclophosphamide and dexamethasone
(dispensed Day 1 of each cycle)
Follow-Up
VERIFY APPOINTMENTS
Verify next day appointment(s) have been scheduled. See follow-up section on Day 1.
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ZZtestonc,Andrew [2428787]
11/15/2016 3:42:45 PM Page 16 of 16
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org